Mechanical ventilation and weaning: Roles and competencies of intensive care nurses and patients' experiences of breathing.

The papers III and IV of this thesis are not available in Munin. Paper III: Haugdahl, H. S., Storli, S. L., Meland, B., Dybwik, K., Romild, U., Klepstad, P.: “Underestimation of Patient Breathlessness by Nurses and Physicians During a Spontaneous Breathing Trial”. Available in American Journal of Respiratory and Critical Care Medicine 2015, 192(12):1440-1448. Paper IV: Haugdahl, H. S., Dahlberg, H., Klepstad, P., Storli, S. L.: “The Breath of Life. Patients’Experiences of Breathing During and After Mechanical Ventilation”. (Manuscript).Breathlessness is an under-recognized problem in intensive care. The overall aims of this study were to explore the roles and competencies of nurses in mechanical ventilation (MV) and weaning, and to explore patients’ experiences of breathing during and after mechanical ventilation. A multimethod design included: survey data from leaders in Norwegian ICUs, interviews and field observations of intensive care nurses in concrete weaning situations, a prospective observational study of 100 mechanically ventilated patients’ self report of breathlessness and, a qualitatively driven sequential mixed method design combining prospective observational breathlessness data during MV and data from follow-up interviews. We found that breathlessness was prevalent among mechanically ventilated patients (62%), and underestimated by nurses and physicians, regardless of expertise or experiences. MV patients’ experiences of breathing were not necessarily a separate experience, but intertwined with the whole illness experience and existential dimensions of life. The nurses’ roles in MV and weaning are their continuous presence and vigilance detection of early changes in the patients’ condition. To acknowledge the presence and impact of breathlessness seems important. Knowing the patient and facilitating well-being was a crucial part of competence in weaning and opened up for establishing trust and confidence, which were necessary to reach into the patients’ world and “pull” the patient back to life, to the “here and now”. This “pulling” was connected to “pushing” the patient further in the weaning process. A potential link between breathlessness and post-intensive care syndrome is an argument for patients’ own reports of breathing to form part of nursing interventions and follow up supporting the patients’ quest for meaning. To enhance the quality of care in MV and weaning, intensive care nurses have an important role in the interprofessional team in order to discuss, reflect and learn how to assess and respond to patients’ experiences of breathing

Paediatric diaphragm function and mechanical ventilation

Thesis (MScPhysio)--Stellenbosch University, 2018.ENGLISH SUMMARY : Introduction: A relationship between diaphragm dysfunction and poor mechanical ventilation outcomes, such as prolonged duration of mechanical ventilation, weaning difficulties and extubation failure have been identified in the adult population. Most of the research of diaphragm dysfunction during mechanical ventilation has been done in the adult population and data in the paediatric population are lacking. The aim of this thesis is to report on diaphragm function in mechanically ventilated paediatric patients. Methods: A literature overview was done to describe mechanical ventilation weaning practices in the paediatric population; as well as underlying reasons for extubation failure in the paediatric population. Available data on weaning and extubation failure in the critically ill paediatric population were summarised. A pilot study was performed to describe the inter- and intra-rater reliability of diaphragmatic ultrasound to measure diaphragm thickness in mechanically ventilated infants and children. Two researchers measured diaphragm thickness using ultrasound in five mechanically ventilated infants and children to compare measures. A prospective observational study was performed to describe diaphragm function in mechanically ventilated infants and children. Diaphragmatic ultrasound was used to measure diaphragm resting thickness and diaphragm contractile activity, and surface electromyography was used to measure diaphragm electrical activity over a period of mechanical ventilation. Serial measures were taken each day of mechanical ventilation and patients were followed up until two days after extubation. Results: The literature overview results showed no consensus in current clinical practice on weaning criteria or protocols, and most current practice is guided by results from adult studies. Several factors have been identified in the paediatric population that may predispose to extubation failure. Respiratory muscle function has been identified as a factor that should be assessed before an extubation attempt as it may be a contributing factor to successful extubation. Diaphragmatic ultrasound has shown to have excellent intra-rater (Intraclass correlation coefficients between 0.77 and 0.98) and inter-rater (Intraclass correlation coefficient: 0.94) reliability to measure diaphragm thickness in mechanically ventilated infants and children. Diaphragmatic ultrasound and surface electromyography are feasible and safe to use to measure diaphragm resting thickness, contractile activity and electrical activity in mechanically ventilated infants and children. Changes in diaphragm function occurred during mechanical ventilation in infants and children, although all measures seem to remain within a common range in the paediatric population. Scatter plots showed that changes in diaphragm contractile activity were associated with increased mechanical ventilation duration, although not statistically significant; no other associations were made between diaphragm function and mechanical ventilation outcome. Conclusion: More research will need to be done to identify how ultrasound and electromyography measures of diaphragm function are associated with mechanical ventilation outcome; and therefore how they could aid in predicting patients that may be at risk for poor mechanical ventilation outcomes. This thesis provides novel data on diaphragm function in mechanically ventilated infants and children which could be used as a basis for further research.AFRIKAANSE OPSOMMING : Inleiding: 'n Verhouding tussen diafragma-disfunksie en swak meganiese ventilasie uitkomste, soos langdurige tydsduur van meganiese ventilasie, speenprobleme en ekstubasie mislukking, is in die volwasse bevolking geïdentifiseer. Die meeste van die ondersoeke na diafragma-disfunksie tydens meganiese ventilasie is in die volwasse bevolking gedoen en data in die pediatriese bevolking ontbreek. Die doel van hierdie tesis is om verslag oor die diafragma-funksie in meganies geventileerde pediariese pasiënte te lewer. Methode: 'n Literatuuroorsig is gedoen om meganiese ventilasie speen praktyke in die pediatriese bevolking; sowel as die onderliggende redes vir ekstubasie mislukking in die pediatriese bevolking te beskryf. Die beskikbare data oor speen- en ekstubasie-mislukking in die kritiese siek pediatriese populasie was opgesom. 'n Loodsstudie is uitgevoer om die inter- and intrarater betroubaarheid van diafragmatiese ultraklank te beskryf om diafragma dikte in meganies geventileerde babas en kinders te meet. Twee narvorsers het diafragma dikte in vyf meganiese geventileerde babas en kinders deur middel van ultraklank gemeet, en die metings vergelyk. 'n Prospektiewe studie is uitgevoer om diafragma funksie in meganies geventileerde babas en kinders te beskryf. Diafragmatiese ultraklank is gebruik om diafragma rustende dikte en diafragma kontraksie aktiwiteit te meet, en oppervlakselektromieografie is gebruik om die elektriese aktiwiteit van die diafragma te meet oor 'n tydperk van meganiese ventilasie. Opeenvolgende metings is elke dag geneem tydens meganiese ventilasie en pasiënte is opgevolg tot twee dae na ekstubasie. Resultate: Die literatuuroorsig resultate toon geen konsensus in huidige kliniese praktyk oor speenkriteria of protokolle nie, en die praktyk word meestal gelei deur die resultate van studies in die volwassende bevolking. Verskeie faktore is geïdentifiseer in die pediatriese populasie wat kan lei tot ekstubasie mislukking. Respiratoriese spierfunksie is geïdentifiseer as 'n faktor wat geassesseer moet word voor 'n ekstubasiepoging, aangesien dit 'n bydraende faktor tot suksesvolle ekstubasie kan wees. Diafragmatiese ultraklank het getoon dat dit 'n uitstekende intrarater(intraclass correlation coefficient tussen 0.77 en 0.98) en interrater (intraclass correlation coefficient 0.94) betroubaarheid het om diafragma dikte in meganies geventileerde babas en kinders te meet. Diafragmatiese ultraklank en oppervlakselektromyografie is haalbaar en veilig om te gebruik om die diafragma se dikte tydens rus, kontraksie aktiwiteit en elektriese aktiwiteit in meganies geventileerde babas en kinders te meet. Veranderinge in diafragma-funksie het plaasgevind tydens meganiese ventilasie by babas en kinders, alhoewel alle metings blyk om binne 'n algemene reikwydte vir die pediatriese populasie te bly. n’ Strooi plot verwys dat veranderinge in diafragma kontraksie aktiwiteit is geassosieer met verlengde tydeperk van meganiese ventilasie, hoewel daar geen statistiese betekenis is nie; geen ander assosiasie tussen diafragmafunksie en meganiese ventilasie uitkoms is gemaak nie. Gevolgtrekking: Ventilasie praktyke in die perdiatriese bevolking is nie gestandardiseer nie. Alhoewel ultraklank meting van die diafragma ‘n betroubare meting is, is die interpretasie van die meting steeds onduidelik. Meer navorsing moet gedoen word om te identifiseer hoe ultraklank en elektromieografie metings van diafragma funksie geassosieer kan word met meganiese ventilasie uitkoms; en of die metings kan help met die voorspelling van pasiënte wat moontlik 'n risiko vir swak meganiese ventilasie uitkomste kan hê. Hierdie tesis voorsien unieke data om diaphragma funksie in babas en kinders wat as basis vir verdere navorsing in hierdie veld gebruik kan word

Identifying ICU patient safety priorities within a Northern Ontario setting : a delphi study

The purpose of this study was to explore patient safety priorities as perceived by clinical experts working in a northern Ontario adult ICU. A modified Delphi was used to elicit consensus regarding patient safety priorities from the perspective of an expert panel of registered nurses and intensivists. At the onset of the study, the consensus level was set at 70%. Data was collected through serials rounds with researcher-developed questionnaires. Descriptive statistical analysis was completed. No consensus was reached at Round 1. Three points of consensus regarding patient safety priorities were reached at Round 2: improving pain and agitation management; incorporating a checklist into the bullet round reporting tool; and implementing use of visual cues for high-risk lines. These strategies support the need for anticipation, recognition, and management of at risk situations. The results have the potential to guide the advancement of the patient safety mandate within an ICU setting.Master of Science (MSc) in Nursin